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General NPI Number Information
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NPI Number | 1720235518
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Entity Type | Organization
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Legal Business Name | THERAPY CENTER VALDOSTA, LLC
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Dates
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Enumeration Date | 08/22/2008
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Last Update Date | 08/25/2008
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Provider Practice Location Address
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Address Line | 103 WAYNE AVE
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City | VALDOSTA
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State | GA
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Zip | 31602-2582
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Country | US
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Telephone | 229-244-9688
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Fax |
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Provider Business Mailing Address
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Address Line | 103 WAYNE AVE
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City | VALDOSTA
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State | GA
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Zip | 31602-2582
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Country | US
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Telephone | 229-244-9688
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Fax |
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Authorized Official
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Title or Position | MARRIAGE AND FAMILY THERAPIST
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Name | MRS. ALEXIS CALDWELL SWORDS
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Credential |
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Telephone | 229-630-9392
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 004372
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 003066
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 057511
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License Number State | GA
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